Kudigo Edited 1

ORDERS

INTERNAL MEDICINE ADMISSION Please admit to room of choice/near nurses/ ICU under the service of Dr._____ Monitor VS Q4H/QHourly and record Diet: NPO/DAT/Low Salt and Low fat Venoclysis: PNSS 1L x __cc/H LABS: CBC, APC, U/A, S. Na, K, Ca, FBS, Crea, SGPT, Lipid Profile, Uric Acid, ECG 12 Leads, Chest Xray, CBG now(routine) Meds: S/O: MIO Qshift and record Stool and vomitus count sheet (diarrhea and vomit) Replace GI losses vol/vol w/PLR Relay labs once in Will inform Dr.___ of this admission Watch out for any untowards S/Sx Refer accordingly Thank you. Resident/Intern

(-)erythema (-) induration

(-/+)dry lips (-/+)dry tonque

T: P: R: BP: (-)headache (-) vomiting (+)able to flex spinal anesthesia

SKIN TEST *Negative Skin Test(NST) to CEFUROXIME(Zegen) *NST to Generic(Brand) IV FOLLOW UP *IVF to ff: D5LR 1Lx 100cc/H Resident/Intern (Refer to the latest IV of the patient/or ask the nurse) TRANSFER OUT TRANSOUT ORDERS *May Transfer Patient Back to Room *D/C O2 and Pulse Oximeter *Monitor VS Qhourly and record knees=for *MIO QHourly and record, *Refer for UO38.5C(10mg/kg/dose) *Ranitidine __mg Q8H SIVTT(NPO)(1mg/kg/dose) *Metronidazole __mg/ml; __ml Q8H IVTT(30-50mg/kg/day) S/O: Fast Drip __CC of PLR now MIO Qshift and record Stool and vomitus count sheet Replace GI losses vol/vol w/PLR Relay labs once in Will inform Dr.___ of this admission Watch out for any untowards S/Sx Refer accordingly Thank you.

ACUTE TONSILLOPHARYNGITIS EXUDATIVE/NON-EXUDATIVE Please admit to room of choice under the service of Dr._____ Monitor VS Q4H and record Diet: NPO/DAT Venoclysis: LABS: CBC, APC, S. Na, K, U/A, F/A, Chest Xray APL Meds: *Cefuroxime 20-40mg/kg/day(ORAL) or 50-100mg/kg/day(IV) TID *or Co-amoxiclav 30-50mg/kg/day TID *Paracetamol __mg/__ml;__ml Q4H prn for fever 37.838.5C(10mg/kg/dose) *Paracetamol__mg prn for fever >38.5C(10mg/kg/dose) *Ranitidine __mg Q8H SIVTT(NPO)(1mg/kg/dose) S/O: MIO Qshift and record Replace GI losses vol/vol w/PLR Relay labs once in Will inform Dr.___ of this admission Watch out for any untowards S/Sx Refer accordingly Thank you.

BRONCHIAL ASTHMA IN ACUTE EXCACERBATION Please admit to room of choice under the service of Dr._____ Monitor VS Q4H and record Diet: DAT/ NPO(tachypneic) Venoclysis: LABS: CBC, APC, S. Na, K, U/A, F/A, Chest Xray APL Meds: *Salbutamol ½ nebule +2cc of PNSS; PAI 1 nebule x 3 doses every 15mins(DOB) *Salbutamol ½ nebule+2cc PNSS Q8H prn for DOB *Hydrocortisone(5mg/kg/dose)Q4H S/O: 02 at _LPM/standby O2 at bedside MIO Qshift and record Relay labs once in Will inform Dr.___ of this admission Watch out for any untowards S/Sx Refer accordingly Thank you.

DENGUE FEVER W/ OR W/o WARNING SIGNS or SYSTEMIC VIRAL INFECTION Please admit to room of choice under the service of Dr._____ Monitor VS Q4H and record Diet: NPO/DAT Venoclysis: LABS: CBC, APC, S. Na, K, U/A, F/A, Chest Xray APL, Dengue NS1Ag, Blood and Rh Typing Meds: *Paracetamol __mg/__ml;__ml Q4H prn for fever 37.838.5C(10mg/kg/dose) *Paracetamol__mg prn for fever >38.5C(10mg/kg/dose) *Ranitidine __mg Q8H SIVTT(NPO)(1mg/kg/dose S/O: MIO Qshift and record Relay labs once in Will inform Dr.___ of this admission Watch out for any untowards S/Sx Refer accordingly Thank you.

BENIGN FEBRILE CONVULSION Please admit to room of choice/PICU under the service of Dr._____ Monitor VS Q4H and record Diet: NPO temp Venoclysis: LABS: CBC, APC, S. Na, K, U/A, F/A, Chest Xray APL Meds: *Diazepam(0.2mg/kg/dose) *Paracetamol __mg/__ml;__ml Q4H prn for fever 37.838.5C(15mg/kg/dose) *Paracetamol__mg prn for fever >38.5C(15mg/kg/dose) S/O: MIO Qshift and record Seizure precautions at bedside Stand by O2 at bedside Relay labs once in Will inform Dr.___ of this admission Watch out for any untowards S/Sx Refer accordingly Thank you.

HYPERSENSITIVITY REACTION Please admit to room of choice/ PICU under the service of Dr._____ Monitor VS Q4H/QHourly and record Diet: Hypoallergenic Diet Venoclysis: LABS: CBC, APC, S. Na, K, U/A, F/A, Chest Xray APL Meds: *Epinephrine 0.3cc IM now *Diphenhydramine(1 mg/kg/dose)IV now *Hydrocortisone (5mg/kg/dose) Q8H *PAI Salbutamol 1 nebule +2cc NSS Q15 mins x 3 doses S/O: MIO Qshift and record Relay labs once in Will inform Dr.___ of this admission Watch out for any untowards S/Sx Refer accordingly Thank you. Resident/Intern

FLUIDS AND FORMULAS

FLUIDS INTERNAL MEDICINE Admitted on any diet *Plain Normal Saline Solution(PNSS) To Hydrate Acute gastroenteritis Patient’s *Use Plain Lactated Ringers Example order: *Venoclyis:PNSS 1Liter X125cc/H ELECTROLYTE SOLUTIONS IV Sol’n D5W D10W 0.9 NSS D5LR D5NM D5NR D5 0.9 NaCl D5NMK

Glu 5mg/L 100mg/L

Sol’n ECF D5LR

Na 142 130

Na

Cl

K

Ca

HCO3

154 130 40 140

154 109 40 98

4 13 5

3

28

40

40

30

50 mg/L 50 mg/L

Cl 103 109

K 4 4

HCO3 27 28

Ca 5 5

Mg 3

D5 0.45 3% NaCl 0.9 NaCl

77

77

513

513

154

154

D5W Osm = 278 D5LR Osm = 130

D5W Osm = 556 NaHCO3 = 446

ELECTROLYTES a) Corrected Ca = (40-lbs) x 0.02 + serCa b) Corrected Na = Na + RBS mg% - 100 x 1.6 / 100 c) Na Deficit = (140 – actual) (0.6 x BW) d) K Deficit = (D-A) (0.4 x BW) D = 3.5 cardiac 4.5 non-cardiac H20 Deficit = 0.6 x kg BW D = 15 CKD 18 NCKD Actual Na – Desired Na / Desired Na CUSHING’S TRIAD 1) Increase systolic BP 2) Widened pulse pressure 3) Bradycardia /AbN˚ respiratory pattern a. Cheyne Stoke breathing

HEMORRHAGIC STROKE TRIAD 1) Papilledema 2) Headache 3) Vomiting MEIG’S SYNDROME 1) Pleural Effusion 2) Polycystic Ovary / Fibromatosis Hypoalbuminemia FORMULAS Mean Arterial Pressure MAP=Systole+2Diastole 3 BMI=kg/m2 50 Super morbid obese BSA=

wt x kg 3600

Creatinine Clearance: CrCl= (140-age) X BW 0.72Xcrea(mg/dl) *for females use 0.85 instead of 0.72 Wasting= actual weight X 100 Ideal wt for age >90%- normal 70-80%- moderate 80-90%- mild 95%- normal 80-90%- moderate 90-95%- mild 200); (PEEP ≤5cm H20) 2. Intact cough and airway reflexes 3. No vasopressor agents being administered FAILURE: 1. RR ≥35 BPM for 5 minutes 2. O2 sat 140 BPM; 20% increase/decrease from baseline 4. Systolic BP 180 mm Hg 5. Increase anxiety diaphoresis SUCCESSFUL 1. Breathing ratio of RR to TV in L 35 3) PaCO2 > 50 4) PaO2 0.6 1.

10) To deliver high FIO2 11) Absent 12) pH 60 mmHg w/ FIO2 < 50% 3) PEEP < 5 cm 4) PaCO2 < pH acceptable 5) Spontaneous TV < 5mL 6) VC > 10 ml/kg 7) MIP > 25 cm H20 8) RR < 30/min 9) Rapid shallow breathing index < 100 (RBI) 10) Stable vs. Ft a 1-2 hr Spontaneous Trial FIO2 room air 21% O2 via nasal prong = # lpm x 0.4 x 20

IDEAL PEAK FLOW Ideal peak flow: Hg (m) – 100 x 5 (+) 175 (M) (+) 170 (F) N ≥ 80% PEFR = Peak flow reading / Ideal peak flow x 100 = _____ % N ≤ 20% PEFR variability: Highest reading – Lower x 100 = ______ % Highest Reading

1. 2. 3. 4. 5. 6. 7.

Criteria for Admission for CAP RR > 28 BPM BP 50% lymph >50% PMS LIGHT’S CRITERIA (exudative if any one of the ff) 1. Pleural CHON/ Serum CHON >0.5 2. Pleural LDH/Serum LDH >0.6 3. Pleural LDH >2/3 upper limit

WHO guidelines for PTB 3 Initial Cont New smear positive TB with 2 HRZE 4HRE extensive parenchymal involvement; new case of severe form of extrapulmo TB II Sputum smear positive 2 HRZES + 5 HRE relapse; txt failure; txt 1 HRZE interruption III New smear neg PTB; new less 2 HRZ 4HRE severe form of extrapulmonary TB H-Isoniazid; R-Rifmapicin; Z- Pyrazinamide; E-ethambutol; SStreptomycin Cat 1

First line Drugs in TB Dosage Metab 5mg/kg/day Liver

Drug H

Action Cidal; Both

R

Cidal; Both

10-20 mg/kg/day

Liver

Z

Cidal;

20-30

Liver

S.E. Hepatitis; safest in pregnancy Hepatitis; hemolysis; thrombocytopenia Most hepato-

E S

intracel l- lular ONLY Static; Both Static; Extrace ll

Class

Exposure

0 1 2 3 4 5

(-) (+) (+) (+) (+) (+)

mg/kg/day

toxic

15-20 mg/kg/day 10-18 mg/kg/day

Kidneys

Optic neuritis

Kidneys

8th nerve palsy

PTB Classification (ATS) Infection CXR infiltrates (-) (-) (+) (+) (+) (+)

(-) (-) (-) (+) (+) (+)

Active Disease (-) (-) (-) (+) (-) (+/-)

CARDIOLOGY ‘

Leads Corresponding Areas II, III, AVF Inferior wall I, AVF High Lateral V1, V2 Septal V3,V4 Anterior V5, V6 Lateral V1-V3 Anteroseptal V3-V6, I, AVL Anterolateral Mirror image of Posterior V1 and V2 All Diffuse/ global V3R, V4R RV wall LOCATING MYOCARDIAL DAMAGE Anterior = V2-V4 (L) coronary, LAD Anterolateral = I, qV1, V3 – V6, LAD, circumflexes Anteroseptal = V1-V4, LAD Inferior = II, III, aVF, (R) coronary artery Lateral = I, aVL, V5, V6, circumflex brance of (L) coronary artery Posterior = V8 – V9 (R) coronary artery, circumflex artery (R) Ventricular = V4R, V5R, V6R, (R) coronary artery

Aortic Stenosis Aortic Regurgitation Mitral Stenosis VSD/Mitral Tricuspid Incompetence MVP PDA` I II III IV V VI

COMMON MURMURS Crescendo-descrendo systolic murmur High pitched blowing murmur Rumbling late diastolic murmur following a snap Holosystolic blowing murmur

Systolic murmur with mid systolic click seen in young women Continuous machinery like murmur MURMUR GRADING

So faint Quiet but can be heard by stethoscope Loud Moderately loud with thrill Very loud, audible with stet partly off the chest Very loud, audible with stet removed from the chest

Type 1 Type 2 Type 3

AORTIC ANEURYMS De Bakey Ascending Aorta and beyond Ascending Aorta only Aorta distal to the subclavian A.

Type A Type B

Ascending Descending

Stanford

5 Dressler’s Sign of Post-MI Pericarditis 1. Pericarditis 2. Pneumonitis 3. Pleuritis 4. Pyrexia 5. Pain

KILIPS CLASSIFICATION OF AMI with EXPECTED HOSPITAL MORTALITY RATE Class Clinical Presentation Expected I No signs of pulmonary or venous 0-5% congestion II Moderate heart failure or (+) of 10-20% bibasal rales, S3 gallop, tachypnea or sings of R heart failure inc. venous and hepatic congestion III Severe heart failure, rales >50% of 35-45% the lung fields or pulmonary edema IV Shock with systolic pressure of 85-95% 2 flights of stairs but with difficulty) Dyspnea occurs with less than ordinary physical activity (climbs ≤2 flights of stairs) Dyspnea may be present even at rest

Therapeutic Classification of CHF A No restrictions B Severe effort restricted C Ordinary effort moderately restricted D Ordinary effort markedly restricted E Confined to bed/chair FRAMINGHAM CIRTERIA FOR DIAGNOSIS OF CHF MAJOR CRITERIA  Paroxysmal Nocturnal Dyspnea  Neck vein distention  Rales  Cardiomegaly  Acute pulmonary edema  S3 gallop  Increased venous pressure (>16 cmH20)  Positive hepatojugular reflux MINOR CRITERIA  Extremity edema  Night cough  Dyspnea on exertion  Hepatomegaly  Pleural effusion  Vital capacity reduced by one-third from normal  Tachycardia (>120 bpm) MAJOR OR MINOR = Weight loss of >4.5 kg over 5 days tx

2-5 µg/kg/min 5-16 µg/kg/min >15 µg/kg/min

Dopamine Drips Vasodilator effect in the renal vasculature Modest increase in myocardial contractility and rate Vasoconstrictive agent

DOPAMINE COMPUTATION Single strength = BW x desired dose / 13.3 Double strength = BW x desired dose / 16.6 Single strength = BW x desired dose / 16.6 Double strength = BW x desired dose / 33.2 Cardiac Dose = 5 Renal Dose = 5-10

NEUROLOGY

Glascow Coma Scale Eyes 1. No response 2. To pain 3. To command 4. Spontaneously Verbal Response 1. No response 2. Incomprehensible words 3. Inappropriate words 4. Disoriented and converses 5. Oriented Motor Response 1. No response 2. Decerebrate 3. Decorticate 4. Withdraws to pain 5. Localizes pain 6. Obeys to verbal command MUSCLE STRENGTH O – No muscular contraction 1 – Trace contraction 2 – Active movement with gravity eliminated 3 – Active movement against gravity 4 – Active movement against gravity & slight resistance 5 – Against full resistance

DIAZ STROKE SCALE Character Grade Vomiting 4 LOC - Unarousable 4 Drowsy 2 Awake 0 Fever 3 Respiratory pattern Ataxic/apneustic 3 Hyperventilation 2 Cheynes-strokes 1 Regular/Normal 0 Upper GI bleed 3 Neuro deficit (max at onset) 2 Headache 2 Nuchal rigidity 2 DBP 100 2 SBP 90 Diagnose and treat with preserved progression, GFR comorbid conditions; dec CV risk Mild kidney 60Estimate rate of disease 89 progression Moderate 30Treat complications; 59 ESRD, education Severe 15Prepare for ESRD 29 treatment Kidney failure 100 mg/dL or creatinine >10mg/dL  Note: For acute renal failure it is best to start dialysis early

GASTROENTEROLOGY

Ranson’s Criteria for Acute Pancreatitis At admission or diagnosis  Age >55 yo  Leukocytosis >16,000 per cubic millimeter  Hyperglycemia >11mmol/L (>200 mg/dL)  Serum LDH >400 IU/L  Serum AST >250 IU/L During initial 48 hours  Fall in hematocrit by >10%  Fluid deficit >4000mL  Hypocalemia 38 or 24/min 3. Tachycardia >90/min 4. Inc WBC >12, 000 5. Dec WBC 10% Bands DEFINITIONS USED TO DESCRIBE THE CONDITION OF SEPTIC PATIENTS Bacteremia  Presence of bacteria in blood as evidenced by positive blood culture Septicemia  Presence of microbes and their toxins in the blood SIRS  Systemic inflammatory response syndrome  Two or more of the following conditions: o Fever (oral temp >38˚C) or hypothermia (90 bpm) o Tachypnea (>24 bpm) o Leukocytosis (>12,000/uL) or Leukopenia ( 10% bands may have a non-infectious etiology

Sepsis  SIRS that has proven or suspected microbial etiology Severe Sepsis  Similar to sepsis “sepsis syndrome”  Sepsis with one or more signs of organ dysfunction Examples 1) Cardiovascular: Arterial systolic blood pressure /= 1 mm in atleast 2 contiguous leads b. ST segment elevation >/= 2mm in atleast 2 contiguous chest leads or c. New LBBB 3. Time from chest pain to thrombolytic treatment a. 200/120 Relative contraindication for thrombolysis 1. Known bleeding diathesis 2. Prev streptokinase treatment for the past 6-9 months 3. BP >/=180/100 on at least 2 readings 4. Active PUD 5. Hx of thrombotic CVA

6. Prolonged CPR >/= 10m or traumatic CPR 7. Diabetic hemorrhagic retinopathy or other hemorrhagic ophthalmic conditions 8. Pregnancy

1. 2.

3.

4. 5.

6.

Criteria for Rheumatoid Arthritis (1987 American College of Rheumatology) (Four out of the seven) Morning stiffness – in and around the joints lasting one hour before maximal improvement Arthritis of three or more joint areas – at least 3 joint areas, observed by a physician simultaneously, have soft tissue swelling or joint effusion, not just bony overgrowth Arthritis of hand joints – arthritis of wrist, metocarpophangeal joint, proximal interphangeal joint Symmetric arthritis – simultaneous involvement of the same joint areas on both sides of the body Rheumatoid nodules – subcutaneous nodules over bony prominences, extensor surfaces or juxtaarticular regions observed by MD Serum rheumatoid factor – demonstration of abnormal amounts of serum rheumatoid by any method for which the result has been positive in less than 5 percent of the normal control subjects

7.

Radiographic changes – typical changes of RA on posteroanterior hand and wrist radiographs which must include erosions or unequivocal bony decalcification localized in or most marked adjacent to the involved joints Criteria 1-4 must be present for at least 6 weeks Criteria 2-5 must be observed by MD 1982 Criteria for Classification of Systemic Lupus Erythomatosus (SLE) 1. Malar rash – fixed erythema, flat or raised over the malar eminences 2. Discoid rash – erythematous raised patches with adherent keratotic scaling and follicular plugging 3.

Serositis – pleuritis or pericarditis documented on ECG, or rub or evidence or pericardial effusion

4.

Oral ulcers – oral and nasopharyngeal ulcers

5.

Arthritis – nonerosive arthritis involving two or more peripheral joints characterized by tenderness, swelling or effusion

6.

Photosensitivity

7.

Hematologic disorder – hematolytic anemia or leukopenia (